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According to the psychoevolutionary theory of emotion, the adaptive function
of emotion depends on the smooth flow of the entire emotional chain. In situations
where links between two constructs are distorted, the entire process
from stimulus to behavior and subsequent effect becomes problematic. Unfortunately,
in modern organizational settings, there are many factors such as
76 LIU AND PERREW E
intense competition and large-scale environmental change (Cascio, 1995) that
may hinder or block the adaptation process, as is discussed in detail in later
sections.
At each of the linking point in the proposed model two possibilities coexist,
both of which may lead to CWB. The first occurs where the link is hindered,
blocked, or distorted. For example, when a feeling of anger toward a customer
cannot be expressed due to organizational policies, it is then redirected toward
organizational property or coworkers. The second is when the chain functions
smoothly but in a way that harms the organization. For example, an outburst of
extreme anger in the case just mentioned may be due to the accurate appraisal
of the situation (e.g., abuse by the customer) and be effective in helping the
person regain emotional balance (i.e., fulfill the goal of emotions). However,
such expression of anger clearly has negative implications for organizational
outcomes (e.g., customer satisfaction and retention). Thus, even adaptive
emotions may lead to CWB.
A Taxonomy of CWB Based on Emotion
To understand better how emotional adaptation and maladaptation affect
CWB, we have developed a taxonomy of CWB. It should be noted that the emotional
chain might be adaptive and functional from the perspective of individual,
but not necessarily be so from the social perspective of the society, which
is, in our case, the organization.
As indicated in Fig. 4.2, based on the notion of emotional adaptation, CWB
can be classified into four different categories according to its individual and
social implications. We propose that the conventionally defined CWBs, such as
abuse of others, threats, work avoidance, and sabotage (Fox et al., 2001), are
behaviors that are adaptive from the individual's perspective but maladaptive
from the social perspective. However, there are three other forms of CWB that
are understudied. First are those CWBs that are maladaptive to both individual
and society, including self-destruction, drug use, and depression (as shown in
the bottom left quadrant in Fig. 4.2). Second are those that are maladaptive individually
but seem to be adaptive socially at the surface level (see the bottom
right quadrant in Fig. 4.2). Such behaviors include passive emotional regulation
behaviors such as suppression of negative emotional expressions (Gross,
1999) and surface acting when performing emotional labor (Grandey, 2000;
Hochschild, 1983). This type of behavior is maladaptive in the sense that it
may be harmful for the physical and psychological well-being (Grandey, 2000;
Gross, 1998b; Hochschild, 1983), as well as the cognitive ability, of individuals
(Gross & Levenson, 1997; Richards & Gross, 2000). Finally, CWBs that are
adaptive both to the individual and the immediate social groups (see upper left
quadrant in Fig. 4.2). This includes deviant behaviors (e.g., stealing) attempting
to adhere to certain organizational cultures or group norms. Viewing CWB
4. COUNTERPRODUCTIVE WORK BEHAVIOR 77
Emotional adaptation from the social
perspective
FIG. 4.2. A taxonomy of CWB as employee emotional adaptation behaviors.
from the emotional adaptation perspective highlights that these three forms of
CWB should be emphasized in organizational research since they could be
harmful equally to the individual and the organizational well-being.
In the preceding subsection, we discuss situations where a linking point in
the emotional chain becomes problematic, which, we propose, is how CWB is
induced. It is important to understand that although CWB can be induced
when only one of the linking points become problematic (i.e., each problem
point can lead directly to CWB), it is through the mechanism of the entire
emotional chain that the antecedents of CWB function. Thus, we cannot understand
fully the process of the influence without examining the complex
chain of emotional adaptation. In other words, viewing CWB from this perspective
helps to better understand CWB.
Stimuli and Cognition
The organizational context has a strong influence over individual behaviors.
Events occurring daily in the workplace can serve as important antecedents of
strong emotional and behavioral reactions (Weiss & Cropanzano, 1996). Injustice
events are likely to induce CWB (Greenberg & Barling, 1999). For example,
supervisor's emotional abuse of subordinates has been found to be associ78
LIU AND PERREW E
ated with pervasiveness of fear and breakdown of employees (Harlos & Pinder,
2000). Many extreme cases of workplace aggression and violence also seem to
be direct responses to workplace injustice (Cropanzano & Greenberg, 1997).
We argue that organizational injustice should be related positively to CWB
through cognition and/or feelings.
However, it is usually not the objective event itself that serves as the immediate
cause of CWB. In the organizational setting, people actively construct
their own realities based on the limited information readily available, and
through the socialization and collective sense-making with other organizational
members (Weick, 1979). Thus, it is important to examine individuals'
cognitive appraisal of a stimulus event beyond its objective attributes. Both individual
differences (e.g., attribution style) and contextual factors (e.g., environmental
uncertainty) influence individuals' cognitions. We discuss both factors
in detail next.
Attribution Style. Attribution style is a traitlike individual characteristic
that directs the individual's attention when one makes causal reasoning. Attribution
styles influence individuals' appraisals as to their relationship to the situation.
For example, individuals who have an external attribution style tend to
attribute success or failure to the environment; in contrast, those with an internal
attribution style tend to attribute success or failure to themselves.
There is evidence that attribution style influences the relationship between organizational
frustration and CWB, such that, in reaction to frustration, individuals
who tend to make external attribution are more likely to sabotage than
their internal counterpart (Storms & Spector, 1987). It has also been proposed
that individuals who have an external attribution style are more likely to exhibit
aggressive and violent behaviors as a result of aversive outcomes than employees
who tend to make internal attributions (Martinko & Zellars, 1998). Thus,
it is reasonable to expect that individuals' attribution style will influence their
cognitive appraisal of events.
Environmental Uncertainty. The modern work environment is characterized
by constant changes, which has resulted in additional pressures both on
organizations and individuals (Cascio, 1995; Greenberg & Barling, 1999). On
the one hand, changes bring about a high level of uncertainty, and therefore
the need to process more information within a constrained time limit. On the
other hand, information gathering and processing become problematic due to
the limited cognitive capability of individuals (Simon, 1997). For example, research
indicates that during threatening situations, individuals, groups, and
organizations tend to become more rigid and rely on less information for decision
making (Staw, Sandelands, & Button, 1981). In addition, there are situations
where management feels it is necessary to withhold information from the
employees for a certain period of time, which makes it more difficult for em4.
COUNTERPRODUCTIVE WORK BEHAVIO R 79
ployees to fully comprehend the actual situation at the time the stimulus event
occurs. Situations simultaneously involving information overload and a lack of
information may increase the possibility of misinterpreting certain events,
which can generate further frustration and stress among employees (Spector,
1997). Increasing stress within the workplace is associated with CWBs, such as
theft (Greenberg, 1990), interpersonal aggression, and sabotage (Chen &
Spector, 1992). However, misinterpretation or distorted perception is also
possible in less stressful situations. For example, role overload and role ambiguity
may influence individuals' feelings of control over situations and affect
further how they perceive situations (Perrewe & Ganster, 1989). Thus, we expect
that individual differences (e.g., attribution style) and situational factors
(e.g., uncertainty) affect the relationship between the stimulus event and the
cognition such that the misinterpretation or distorted perception of work or
life events can occur and lead to CWB. As an example, individuals with an external,
pessimistic attribution style are more likely to interpret stimuli events
negatively. Further, situations that are characterized with uncertainty and
stress are likely to be related positively to employees' misinterpretation of
stimuli events.
Cognition and Feeling
Even with the stimuli being perceived as fully and as functionally as possible,
the cognition may not lead to appropriate feelings that are both adaptive to individuals
and beneficial to organizations. The reasons are twofold. First, the
adaptive feelings may not be elicited from the perception. Second, when the
adaptive feeling is elicited within an employee, it may not be beneficial to
the organization. We discuss each scenario next.
There are a number of factors that will influence people's elicitation of
emotions. In the extreme case, individuals may lack certain kinds of emotions,
such as love or fear. For example, Damasio (1994) reported a subject who lost
his ability to get in touch with his own emotions. More commonly, being in
certain moods may also predispose individuals to feel certain emotions and not
others. For example, an individual in a bad mood may be irritated more easily
than one who is in a good mood. From a social norm perspective, strong display
and feeling rules may influence and, over time, guide individuals to learn not
only what emotions to express but what emotions to experience (Hochschild,
1983; Scherer, 1986; Zurcher, 1982). For example, people may initially find it
appropriate socially to express sadness when attending a funeral, and over time
the perception of a funeral setting will actually generate feelings of sadness inside
the person. In a work setting, when a supervisor reprimands publicly an
employee for a misdeed, even if he or she believes that the comments are justified,
the simple fact of being criticized in public may generate a feeling of
shame or humiliation. Feelings of shame may motivate further retaliation be80
LIU AND PERREWE
haviors toward the supervisor. Thus, we expect that individual factors (e.g.,
disability) and social and organizational norms affect the relationship between
cognition and feelings such that an accurate perception may still lead to an inability
or unwillingness to elicit or express appropriate feelings, which may
further result in CWB.
A more typical case in organizations is when individually and psychologically
adaptive emotions are expressed with a potentially negative implication
for organization, which is especially true when the emotions are ones commonly
viewed as negative (e.g., anger). There are several situational and individual
psychological factors that may induce employee negative feelings.
Injustice. Perceived unfairness is an important situational factor that induces
negative emotions (Spector & Fox, 2002). Two types of justice have
been frequently discussed, procedural and distributive justice. Procedural justice
refers to the degree to which procedures are perceived as fair in decision
making and resource allocation. Distributive justice reflects the perceived fairness
of the rewards employees receive for their performance inputs. Perceptions
of injustice are associated with counterproductive behaviors such as employee
theft, withdrawal, aggression, and other forms of CWB (Fox et al., 2001;
Greenberg, 1990; Greenberg & Barling, 1999). Research illustrates that distributive
justice also induces employee theft in striving to restore a balance between
their rewards and contributions to a job (Greenberg, 1990, 1993). As
suggested by O'Leary-Kelly, Griffin, and Glew (1996), workplace violence may
ensue when employees perceive valued outcomes (e.g., promotions, compensation)
as having been distributed unfairly. In contrast, research also illustrates
that fair procedures can minimize the dissatisfaction resulting from
poor outcomes (Greenberg, 1990) and can promote employee citizenship behavior
(Organ & Ryan, 1995).
Violation of Psychological Contract. Psychological contracts refer to employees'
beliefs about the reciprocal obligations between themselves and their
organization (Rousseau, 1989). It is argued that that the content of psychological
contracts is not always clear and may become difficult for organization to
fulfill, as when organizations undergo dramatic changes such as corporate
restructuring, large scale downsizing, and increased reliance on temporary
workers (McLean Parks & Kidder, 1994; Morrison & Robinson, 1997). Although
such changes are becoming increasingly necessary for organizations
(Cascio, 1995), it may result in various levels of employees' perceptions of violation
of psychological contracts by the organization (McLean Parks &
Schmedemann, 1994; Robinson, Kraatz, & Rousseau, 1994). Similar to distributive
injustice, violation of psychological contracts may also lead to the employee
engaging in behaviors such as theft or sabotage in order to "get even"
(Morrison & Robinson, 1997).
4. COUNTERPRODUCTIVE WORK BEHAVIO R 81
Loss of Control. Perceived control is a critical concept in coping with
stress. Research has found consistently that high level of perceived control
leads to better task performance and a lower level of felt stress appraised
(Averill, 1973; Langer, 1975; Thompson, 1981; Thompson, Armstrong, &
Thomas, 1998). Unfortunately, within organizations, changes such as technology
modernization and large-scale downsizing often introduce considerably
high levels of job insecurity, therefore resulting in feeling of loss of control for
employees (Greenberg & Barling, 1999). Possible consequences of a loss of
control include feelings of powerlessness, loss of identity, anxiety, and stress,
which may result in aggression or other forms of CWB in an effort to regain
feelings of control. Thus, we argue that perceptions of injustice, violation of
psychological contract, and loss of control will affect the relationship between
cognition and feelings. Specifically, when feelings of injustice, a violation of a
psychological contract, and loss of control are high, perceptions of an event
may lead to more negative feelings, which will induce CWB.
Feeling and Behavior
Felt emotions bear strong influence on subsequent behaviors (Weiss & Cropanzano,
1996). Although positive feelings may bind people together (Kemper,
1984) and facilitate interpersonal relationship (Fredrickson, 1998), negative
feelings such as anger and sadness tend to pull people apart (Kemper, 1984).
Research indicates that negative emotions are related to both organizationand
person-targeted CWB (Fox et al., 2001). It is worthwhile noting that the
negative emotions may be adaptive reactions to negative stimulus event in the
strict physiological and psychoevolutionary sense (e.g., anger may serve as
warnings that intend to avoid harmful behaviors of others from happening next
time); however, such individually functional behaviors may become socially
harmful and dysfunctional in a social setting, as demonstrated by angerinduced
aggression (Folger & Skarlicki, 1998). Thus, we argue that the
hedonic tone of felt emotion affects the feeling-behavior relationship such that
negative emotions are positively related to conduction of CWB.
Interestingly, individuals' good intentions to behave in a socially desirable way
can prove equally to be harmful strategically for organizations. For example,
suppression of negative emotions has been found to cause stress among flight
attendants because of the discrepancies between felt emotion and expressed
emotions (Hochschild, 1983). (Boyle discusses this study in detail in a chapter
in this book.) We examine next the influences of social and organizational
norms, as well as feeling rules, on the linkage between feeling and behavior.
Social and Organizational Norms. An individual's behavior is a function
of social influences (Bandura, 1977). Certain organizational culture factors
such as organizational values and integrity influence the extent to which em82
LIU AND PERREW E
ployees engage in CWB (Boye & Jones, 1997). Workgroup context also has a
significant influence on antisocial behaviors of individual employees (O' Leary-
Kelly et al., 1996; Robinson & O' Leary-Kelly, 1998). Further, individuals' antisocial
behaviors become stronger as their group experiences enrich and they
begin to become socialized with the deviant norms (Robinson & O' Leary-
Kelly, 1998). In fact, in some organizations employee theft was so institutionalized
that it served as a symbol indicating the employee was well socialized
within the organization (Altheide, Adler, Adler, & Altheide, 1978).
Social norms also influence an individual's selection of targets to whom
they express particular emotions. For example, anger toward a supervisor
tends to be viewed as highly inappropriate behavior at work. Thus, people who
feel angry with their supervisors may resort to targeting their anger toward coworkers
or subordinates, or even organizational property, which are all potentially
counterproductive.

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3
'You Wait Until You Get Home":
Emotional Regions, Emotional
Process Work, and the Role of
Onstage and Offstage Support
Maree V. Boyle
This chapter explores the connections between emotionalized regions within organizations
and the kinds of emotional process work that occur within these regions.
A study of an emergency service organization over an 18-month period
found that the performance of emotional process work is a vital stage in the overall
performance of emotional labor within this industry. Interviews with emergency
service workers also indicated that a substantial amount of emotional
process work occurs within one of three emotional regions within the organization—
the "offstage" (or nonwork) region. The organization in question, known
here as the Department of Paramedical Services (DPS), relies heavily on informal
"off stage" emotional support. Thoits's (1985) work on emotional process
work and Goffman's (1959) work on regions are used to demonstrate how the individual
management of emotion and the organizational ordering of emotional
regions are intertwined closely. Organizational implications for the overreliance
on offstage forms of support are also discussed briefly.
Although we don't get enough training in how to cope, the expectation is that you
have to cope.... So you can do your job, you can let the tears flow but you still
have to be efficient at what you are doing. At least until you get back to the station.
But that doesn't usually happen. You wait until you get home ...
The principal aim of this chapter is to explore how the existence of emotional
regions within organizations and the individual practice of emotional process
work as part of emotional labor are intertwined. This discussion is based on
qualitative field data collected over an 18-month period within an emergency
45
46 BOYLE
services organization specializing in prehospital emergency care. The organization
in question, the Department of Paramedical Services (known hereafter as
the DPS), could best be described as an emotion-laden organization, where
emotionality is central to the raison d'etre of the organization.
The linkage between emotional regions within organizations and emotional
process work is illustrated through a closer examination of the offstage (or
nonwork) region within the DPS. Thoits's (1984, 1985, 1991) work on emotional
process work and Goffman's (1959) work on regions will also help illustrate
how, in this instance, emotional process work can be "privatized" and
thus removed from the realm of organizational responsibility.
This chapter is divided into the following sections. First, I provide an overview
of the research site and design. Second, I discuss the concepts of emotional
regions, emotional labor, and emotional process work, and how these relate to
the study discussed here. Third, I provide a detailed and richly narrative style account
of the nature of emotional labor and how it is performed within the DPS.
Within this section I also highlight the different approaches to the performance
of emotional labor in front-stage regions, which includes illustrations of surface
and deep acting, and the process of emotional "switching." Fourth, I illustrate
the nature of offstage support within the DPS, and discuss how the overreliance
on this kind of support may leave an organization such as the DPS vulnerable to
the negative financial consequences of occupational stress.
EMOTIONAL CULTURES, REGIONS,
AND DRAMATURGY
Emotional culture within organizations consists of three components: emotional
vocabularies (Gerth & Mills, 1953; Gordon, 1981), emotional norms
(Gordon, 1989; Hochschild, 1979, 1983; Scheff, 1979, 1990), and meanings of
power and status (Kemper, 1978). Gordon (1990) also differentiated between
institutional and impulsive orientations within emotional cultures. Institutional
meanings of emotions are those given by organizational members when
they are in full control of their emotions. Members effect achievement and
maintenance of institutional norms, and in doing so continue to uphold and reproduce
emotional culture (Gordon, 1989).
In formal organizations such as the DPS, the application of impulsive
modes of emotional expression is considered either deviance or indicative of
faulty socialization (Gordon, 1981; Thoits, 1989). However, permission to express
impulsive emotion is granted to those with power and status, typically
middle- and upper-class men of Anglo-Celtic origin (Hochschild, 1983;
Pierce, 1999). These "status shields" also apply to relationships between clients
and organizational members. Those with greater professional status are
less likely to witness impulsive orientations to emotion than those with lower
3. "YOU WAIT UNTI L YOU GET HOME " 47
status (Hochschild, 1983). For example, patients are less likely to exhibit displays
of extreme emotion in the presence of medical consultants than they are
in front of clinical staff that are considered of lower status.
The concept of emotional region is derived from Goffman's (1959) dramaturgical
perspective. Performance, which is a central component of an organization,
is defined as "all the activity of a participant on a given occasion that
serves to influence any of the other participants" (Goffman, 1959, p. 26). Performances
are only successful when individuals can show that their actions are
genuine, while sustaining simultaneously a "front" that is considered authentic
(Goffman, 1959, p. 28).
Successful performance is also staged by teams "who share both the risk and
discreditable information in a manner comparable to a secret society" (Goffman,
1959, p. 108, as cited in Manning, 1992). Teams are organized by "directors"
who manage disputes and delegate responsibility. Teams also act in "front
regions," which are defined as spaces within which they perform for their public
(Goffman, 1959, pp. 102-114). Teams "rehearse, relax, and retreat" to "back regions,"
spaces hidden from publics' view when front region performances are
"knowingly contradicted as a matter of course" (Goffman, 1959, pp. 110-114).
Goffman's (1959) conceptualization of front and back regions is used here heuristically
to develop further Fineman's (1993b) notion of the "emotional architecture"
of organizational culture, in which he suggests within organizations
physical spaces exist in which different feeling rules apply.
The concept of emotional culture builds on Gordon's (1981) original conceptualization,
joining both Goffman's (1959) description of regional behavior
and audience segregation and the differentiation perspective of organizational
culture (Martin, 1992), which recognizes the importance of subcultures.
Therefore, emotional culture can be observed within three "regions"—frontor
onstage, backstage, and offstage. The front-stage sector is where emotional
labor is performed, whereas the backstage sector is where interaction with organizational
members happens and where emotional process work is likely to
occur. In comparison, offstage regions are located outside the physical realm
of the organization itself. As Hosking and Fineman (1990) asserted, differentiation
between front-stage and backstage organizational emotionality helps us
understand the nature and consequence of emotional labor, particularly within
the context of emotional culture.
EMOTIONAL LABOR AND EMOTIONAL
PROCESS WORK
Recent research on the links between the performance of emotional labor and
emotional dissonance indicates that a complex array of factors has both positive
and negative effects on the individual's emotional well-being in the work48
BOYLE
place (Hartel, Hsu, & Boyle, 2002). These factors include the quality of the immediate
workplace emotional climate in which the service encounter occurs
(Ashforth & Humphrey, 1995), the influence of gendered cultural norms
(Wharton, 1993), the degree of job control and routinization (Leidner, 1993;
Van Maanen, 1991), and the quality of organizational responses to stress induced
by emotional labor (Kunda & Van Maanen, 1999).
Early work on the conceptualization and operationalization of emotional labor
created a clear distinction between emotion work and emotional labor
(Hochschild, 1979, 1983). Expanding on Hochschild's (1983) definition of
emotional labor previously discussed, Hochschild (1983) also argued that
emotive dissonance was an inevitable consequence of emotional labor because
it resulted in a transmutation of the private emotional region into the public
commercial region. However, emotion as a process involves the appraisal of a
series of affect-related events, which may involve the experience of discrete or
private emotions such as sadness or envy. Although the context in which the
appraisal and subsequent emotional regulation take place may change from a
public to private one, the process of appraisal, attribution, and regulation of
emotion is essentially the same (Weiss & Cropanzano, 1996).
Therefore, I propose that emotional process work is an integral part of emotional
labor, and is an extension of the service provider-client interaction. In
addition, I also propose that organizational response to this aspect of an employee's
work influences significantly both the quality of the service outcome
and the levels of individual employee stress fitness and emotional health.
Emotional Process Work
Emotional process work occurs before, during, and after a service encounter,
and involves a number of strategies that enable the employee to maintain a
normative emotional state. Thoits (1984, 1985) explained that when emotional
management techniques fail and individuals are unable to deal satisfactorily
with "deviant" or "outlaw" emotions such as disgust, extreme anger, or hatred,
they then have to process this failure as a violation of feeling or expression
norms. Thoits (1985) cited two conditions that she viewed as central to the
prediction of emotion work failure: the persistence of deviant or outlaw emotions,
and the absence of social support. Thoits (1985) explained that when individuals
are committed to competent identity enhancement and are aware of a
discrepancy between situational feelings and emotional norms, attempts at
emotional process work follow, and self-attributions of deviance occur as a result
of persistent failure to create an individual normative state. For example, if
a paramedic felt extreme anger after attending a case such as child abuse, this
would be considered the emotional norm for this particular situation. However,
if the same officer felt nonchalant or disinterested about the same case,
he might attempt to move his feelings closer to the emotional norm for this sit3.
"YOU WAIT UNTI L YOU GET HOME " 49
uation. If he were unable to do this, then he would be more likely to label his
own emotions as deviant.
Therefore, Thoits's (1984, 1985, 1991) work has implications for how emergency
sendee organizations confront the reality of work stress and the maintenance
of appropriate emotional climates within the organization. Within an
emergency service context, emotional process work occurs after a case has been
completed and involves a variety of strategies that are designed to assist the officer
to return to a normative emotional state. The parameters of a normative
state are determined by both societal and organizational cultural norms, and are
influenced by gender, national culture, and generational emotional norms.
Emotional process work may be as simple as one officer acknowledging to another
officer that the previous patient was rude or obnoxious, or it may involve
many weeks of coping with a major traumatic event such as a plane crash. All officers
"do" emotional process work, and the degree to which they accomplish
successfully emotional normality varies according to level of experience, degree
of social support, and ability to cope with the demands of emotional norms and
feeling rules that the organization places on them.
RESEARCH SITE AND DESIGN
The DPS provides prehospital emergency care to subscribers to its service. It
is a public-sector organization that has developed a culture emergent from a
combination of both militaristic and not-for-profit influences. The DPS is a
male-dominated organization, with over 90% of the on-road staff being men.
As part of their duties as "caring" paramedics, the DPS on-road staff are expected
to perform as emotionally complex individuals while simultaneously
adhering to a strict hegemonically masculinist code of conduct. Officers are
expected to display the "softer" emotions of compassion, empathy, and cheerfulness
in public, while refraining from the expression of grief, remorse, or
sadness in the company other officers. Although this expectation is not harsh
in itself, it becomes untenable when the DPS relies heavily on the "privatizing"
of emotional process work.
Using Thoits's (1991) work on social support as a basis, emotional process
work is defined as the emotion work in which officers engage after emotional
labor has been performed. Although this practice incorporates what Hochschild
(1983) referred to as emotional management, in this particular context it
is used to differentiate between the processes used while emotional labor is
being performed, and those utilized to make sense of the interaction to which
emotional labor is central.
In keeping with Hochschild's (1983) original definition, emotional labor is
defined here as the appropriate level of display, feeling, and exchange that occurs
between the service provider and the service recipient. Therefore, the
50 BOYLE
practice of emotional labor includes both individual emotion work and emotion
management of others' feelings. In the DPS context, emotional labor is
specifically defined as the management of the emotional interface between
paramedic and patient, and/or persons located within the vicinity of the interaction
with whom the officer needs to communicate with in order to successfully
accomplish the task at hand.
This ethnographic style qualitative study of the emotional labor practices
within ambulance work utilizes a triangulated approach that involves extensive
observation of work routines and practices. Given that self-reports of intangible
and unobservable feelings and inner emotion work may be difficult to validate
through formal interviews only, I chose this observational methodological
approach because I considered it the most appropriate way of accessing this
kind of data (James, 1993). Document analysis of training and human resource
materials, recruitment practices, and organizational mission statements was
also performed.
My approach to ethnographic research is influenced by the classic anthropological
approach, which requires the researcher to adopt the role of "professional
stranger" (Agar, 1996). According to Van Maanen (1988), this kind of
ethnographic study can be categorized as more of a "critical" than "realist" account
of the culture of the DPS. Therefore, it does not focus exclusively on my
personal experience as a fully immersed participant, but rather is a critical account
of organizational emotionality within the workplace. Although I was
physically and emotionally involved in particular cases, I did not wear a uniform,
was not permitted to comfort or reassure patients, and was not fully accountable
to the DPS as an employee or volunteer. My own experiences in the
field did not involve "doing emotion" in the same way that ambulance officers
did. This psychic distance from the actual work in which officers engaged is
indicative of the well-documented dilemma field-workers face when they are
restricted in their ability to gain unlimited and pure access to informants in the
field (Hubbard, Backett-Milburn, & Kemmer, 2001).
Fieldwork was conducted within the DPS over an 18-month period. During
that time I conducted 500 hours of observation, and attended and partially observed
110 cases. I observed cases with 50 on-road officers, 9 of whom were
women. In addition to these observations, I conducted 30 in-depth interviews
with officers across the 7 DPS geographical regions. I also attended training
sessions, spent time within communication call centers, and held informal
discussions with senior managers and counselors about DPS policies regarding
posttraumatic stress disorder and stress debriefing.
An ethnography is a written representation of either a whole or parts of a culture,
and carries serious intellectual and ethical responsibilities (Van Maanen,
1988). Therefore, every effort has been made to protect the identities of the
paramedics who agreed to be interviewed for this study. The names of these interviewees
have been changed to maintain anonymity. Care has been taken to
3. "YOU WAIT UNTIL YOU GET HOME" 51
choose names that do not correspond with those officers who were observed or
interviewed. At no time during fieldwork were patients' names recorded.

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2
Emotions: From "Ugly Duckling"
Via "Invisible Asset" Toward
an Ontological Reframing
Dorthe Eide
The ability to cope and act in capable ways with and through emotions has become
vital as more people and organizations become involved in work intensive
on social interactions, emotional labor, and/or changes. However, linking emotions
to capable activity challenges traditional views on organizations and knowledge.
This chapter argues that the shift from seeing emotions as an "ugly duckling"
to an "invisible asset" is not sufficient in order to understand emotions in
organizations; a more radical rethinking is needed. A situated-relational ontology
is suggested where emotions are seen as one of the fundamental and inseparable
parts of being human, and consequently also of human knowledge and action in
organizations.
EMOTIONS AND KNOWLEDGE—
INCOMPATIBLE PHENOMENA?
Knowledge and learning processes have gained increased legitimacy in society
and organizations. They are claimed to be critical "invisible assets" and core
processes in order to survive, innovate, and increase competitiveness
(Drucker, 1993, 2001; Nonaka & Takeuchi, 1995; Quinn, 1992). As this claim
becomes stronger, it becomes important—both for functional and for symbolic
reasons—to explore critically what it means to know and work in organizations.
If not, there is a high risk that we will only appreciate the kind of work
and knowledge already understood, and thereby silence other voices of experience,
knowledge, and opinions in organizational life and studies.
11
12 EIDE
During the last decade the calls for rethinking emotions and knowledge increased,
and at least two main alternative research schools have been identified.
One view centers on knowledge processes in organizations where it is argued
that knowledge is a critical resource, but where the idealized theoretical
view of knowledge is argued to be out of touch with the meaning of knowledge
in practice. The other school of thought within research, emotions in organizations,
describes how emotions are present and constitute a vital resource in
work. It also criticizes the traditional "rational" view for taking an overly
dualistic view of cognition and emotions, as well as assuming that cognition
tends to be rational whereas emotions tend not to be (e.g., Domagalski, 1999;
Fineman, 1993a). There are examples where these two schools of thought
overlap—for instance, both tacit knowledge and emotions are argued as invisible
assets and/or human ways of knowing and being.
Rethinking Knowledge in Organizational Studies
The traditional view of emotions and knowledge has a common "root" in a
positivistic/realism (i.e., functionalistic, to use the term of Burrell & Morgan,
1979) paradigm that depicts emotions as the "sand in the machinery" or, in
other words, that emotions prohibit workplace effectiveness. Therefore emotions
and knowledge came to be seen as two dualistic and incompatible phenomena.
Scholars working within an interpretive-constructionist paradigm
have claimed that traditional perspectives on human knowledge are insufficient
(i.e., where knowledge is seen as only or mainly something explicit, "objective,"
general, theoretical, and often technical). Instead, versatile concepts
of knowledge have been suggested (Bruner,
1990; Gherardi, 1999; Lave & Weng- The life—
er, 1991; Polanyi, 1958; Schon, 1983) that and the love of everything—
involve dimensions such as the personal, you must feel your way toward
—with the rough skin of your
relational, and social dimensions; the hands—like a blind person learns
tacit, narrative, and explicit dimensions; the face of her lover
and the local embedded and more gen- through her fingertips.
eral aspects. During the last decade, or- (Hans Borli, 1972, my translation)
ganizational studies have recognized and
focused on knowledge in practice, particularly through the subphenomena of
tacit knowledge and narrative knowledge. Tacit knowledge means knowledge
that is difficult to articulate fully in words; that is, most of what we know is
tacit, and even the more explicit knowledge dwells in the tacit (see, e.g.,
Polanyi, 1966/1983). Narrative knowledge is largely discursive and expressive
in words; it is a story-based way of understanding and makes meaning out of
ongoing experiences in order to know oneself and the world (Bruner, 1990;
Czarniawska, 1997; Polkinghorne, 1988). Both the tacit and the narrative/discursive
are core processes in how people understand in everyday life, and are
therefore central to organizational behavior and the concept of knowledge.
2. EMOTIONS: TOWARD AN ONTOLOGICAL REFRAMING 13
Even though our understanding of knowledge has developed and enlarged,
science still seems to have problems with bringing emotions "back
in" to organizational studies, particularly with regard to knowledge and processes
related to intelligent/capable activity. This is a field that appears to be
among the most dominated by cognition and/or traditional instrumental rationality.
Is this the last "bastion" where emotions are the "ugly duckling"?
When it comes to learning in organizations, emotions have recently been
claimed to be the most promising and unexplored dimension (Hopfl &
Linstead, 1997). Is this the case for knowledge in organizations as well? Yes,
I will argue; the next vital step is to include emotions in studies of learning
and knowledge in organizations.
Toward Integrating and Rethinking Emotions
Ashkanasy (1995, p. 2) argued that it is time to place "Cinderella" in the limelight
and to include emotions in order to make organizational studies "more
complete." In present working life it has become more apparent that human
actions are often emotional because a growing number of occupations and
trades are characterized by emotionally intensive work, especially due to increasing
focus on service quality, customer orientation and rapid changes
(Fineman, 1993a, 2000; Van Maanen & Kunda, 1989). Coping with one's own
and others' emotions seems vital, but can also be difficult. The emotional dimension
can be a smaller part of the service "product" or it can be a critical
part of the core process of customer service (Forseth, 2001). However, indicating
that emotions can be related positively to knowledge does not resonate well
with the traditional and "rational" views on knowledge and organizations.
The main purpose of this chapter is to contribute in the rethinking discourse
of emotions and knowledge. My argument is twofold: First, in order to
grasp human emotions and knowing in practice, we need to engage in a more
radical rethinking that includes an ontological choice. Here a broad situatedrelational
approach (within the interpretive-constructionist paradigm) is suggested.
Second, stemming from this ontology is the basic assumption that
being human involves emotions; therefore, human knowledge can involve
emotions as well. By arguing that emotions have a fundamental role, I do not
mean that other human aspects (e.g., cognition) should be omitted. My point
is not to throw out one for the other but rather to aim for a broader and more
integrated view on human being and human activity.
This chapter is divided into four sections: First, I briefly review traditional
views of emotions in society and organizations. Second, more recent views on
emotions in organizations and work are addressed, particularly the view of
emotions as an invisible asset in emotionally intensive work. Third, an ontological
reframing of emotions and knowledge is suggested and elaborated. Finally,
implications are summarized.
14 EIDE
EMOTIONS AS THE "UGLY DUCKLING"1
Emotions have been viewed as the "ugly duckling" within the triangular of
three distinct faculties of affect/emotion, cognition (how people think, know,
reason), and will (conation, motivation) (Forgas, 2000). During the Victorian
period (about 1820-1920) the prevailing view developing was that emotions
needed to be structured and controlled (May, 1983), whereas reason and science
became the new promising force for industry and governmental activity.
Since this first phase of industrialization, Western cultures and especially science
have mainly celebrated so-called instrumental, rational, and/or cognitive
views on humans and organizations, such as the machine view of organizations
(see Morgan, 1986). Instead of the religious dogma in the Middle Ages, with
one almighty God and truth, science became the new "hero" in the search for
the truth. Personal aspects such as feelings and intuition, as well as other types
of values and rationality (e.g., care and substantial rationality,2 practical sense/
judging), were ignored, suppressed, or in other ways treated as "sand in the
machinery." Emotions were seen as something that characterized primitive
creatures and cultures, including children, women, or artists, and therefore
became as the antithesis of both scientific work and of knowledge (Bendelow
& Williams, 1998; Carnall, 1995; Morgan, 1986).
Existential phenomenology replied by asking, "But what sort of world do
we dwell in?" (Luijpen, 1962, p. 88). Human philosophers (e.g., Heidegger,
1927/1996; James, as cited in Forgas, 2000) recognized a close relationship in
thinking, feeling, and behavior, and started to question and protest against
the rationalism of their time (late part of the 1800s and beginning of 1900s).
Something vital was missing and had gone wrong when natural science ruled
the "playground" alone. Not even psychology assigned much importance to
emotions in the two most dominant paradigms of behaviorism and cognitivism
(Forgas, 2000).
Within organizational studies, Weick (1979) and Fineman (1993a) among
others argued against the "machine" perspective of organizations and human
beings. Bruner (1990) claimed that cognitivism still suffers from insufficiency
due to the machine metaphor assumed when discussing learning and knowledge.
Nonaka (1994) argued that the rational and hierarchical view of organizations
and knowledge hinders the understanding and facilitation of knowledge
creation and innovation. However, this "rational" view is not purely
historical. Ashkanasy (1995, pp. 1-2) argued that research still seems to be
"influenced by the Weberian belief that emotions and feelings are not proper
The term the ugly duckling is inspired by the fairy tale with the same name by the Danish poet
H. C. Andersen.
For example, care rationality has often been seen as female and emotional, opposed to the instrumental
technical/economical rationality, which was seen as a male rationality and where emotions
were excluded (Martinsen, 1989).
2. EMOTIONS: TOWARD AN ONTOLOGICAL REFRAMIN G 15
subjects for serious study." Today an increasing number of researchers have
become aware of the importance of including emotions and more implicit aspects
when studying organizational life and capable action/knowledge. One
may argue that it is high time that management and organizational scholars
start including the everyday emotional life in their studies and theories
(Ashforth & Humphrey, 1995), and then
studying the many sides of emotions and We are left with an image of an
not only seeing them as irrational. actor who thinks a lot, plans, plots
In summary, I argue that the view of and struggles to look the right part
at the right time. But we do not cognition as something more important hear this actor's anger, pain, emthan,
and as something separable from, barrassment, disaffection or passion
other human aspects and meanings is and how such feeling relates to acdefinitely
being challenged. The ques- tions — except when it forms part
tion is, however, are we moving toward of the organizational script.
(Fineman, 1993a, p. 14) more fruitful alternatives?
EMOTIONS IN ORGANIZATIONS—
AN INVISIBLE ASSET?
In more recent writings on emotions in organizations, different perspectives of
emotions are taken. The two most common and complementary conceptual
views are the psychoanalytic and the social constructional perspectives
(Fineman, 1997). The former sees emotions as mainly an inner individual and
private process (see Calori, 1998), whereas the latter argues that emotions are
mainly something relational, social, cultural, and thereby also public (e.g.,
Gergen, 1994; Sandelands & Boudens, 2000; Strati, 1998). Both views can
study what, why, and how feelings are expressed and repressed. For example,
this can be carried out in a study of the differences and similarities between
groups (e.g., the front line vs. the back line). In addition to, or partly overlapping
with, the two views, there is a rapidly growing school of thought—emotional
intelligence—that addresses the role of emotions in capable action and
in learning (see Goleman, 1998; Mayer & Salovey, 1997).
This section does not address the main recent views in depth; instead, I focus
on emotionally intensive work and studies thereof, which tend to draw on
one or more of the three lines. My purpose is to show problems with addressing
emotions mainly as an invisible asset to be utilized and managed in organizations
in instrumental ways. In this way, the examples can be seen as arguments
against stopping the rethinking of emotions, with the idea that
emotions are an invisible asset. In the third section I suggest and elaborate a
third and more radical rethinking. However, first, what is emotionally intensive
work and how can it be problematic?
16 EIDE
Emotionally Intensive Work
Emotions have received increasing atten-
People working in customer service
tion and importance in organizations be- roles find their employers specifying
cause a large, if not the largest, part of the how they act and dress, what they
workforce in Western countries work say and even what they should
within service industries or service work. think and feel...
The number of employees who are paid Service staffs are paid as much for
their "emotional labor" as for their
to express positive emotions and attitechnical
skills.
tudes such as commitment, sensitivity, (Guerrier, 1999, pp. 212 and 234)
care, and hospitality (e.g., through smiling,
greetings such as "welcome" and "have a nice day"), while not expressing
negative emotions or other feelings and identities, are increasing. Such work is
also termed emotional labor and involves emotional management, as one is
supposed to control and manage one's feelings so they are appropriate when
"on stage" with customers. Hospitality and frontline work in particular are often
described as intensive regarding emotions; "the word 'hospitality' conjures
up images of warm, smiling welcomes" (Guerrier, 1999, p. 211). In this
type of work, emotions are argued an "invisible asset," that is, an unrecognized,
intangible and/or central resource in the organizations:
We can think of emotion as a covert resource, like money, or knowledge, or physical
labor, which companies need to get the job done. Real-time emotions are a
large part of what managers manage and emotional labor is no small part of what
trainers' train and supervisors supervise. It is a big part of white-collar "work."
(Hochschild, 1993, p. xii)
Rather than biasing and neglecting emotions, I argue that emotions are
more often seen as an invisible asset for the individual and particularly the organization
both in practice and in the more recent theoretical schools of
thought briefly introduced earlier. One main reason for this change in the view
on emotions (from "ugly duckling" to "invisible asset") seems to be the global
ideas of service management, quality, and customer orientation, and the necessity
of these in successful business transactions. Such ideas are not only
cognitive (i.e., mental models and structures, thinking, and information processing),
they are also embedded with emotions, meanings, and values that direct
and shape the internal and external activities of the involved organizational
members. The service itself is highly intangible, displayed by and
creating feelings and symbols. Learning and maintaining appropriate emotions
through contextual situated "feeling rules" have therefore been argued
to be a central component in service work, both in so-called low-skilled work
(e.g., fast-food restaurants) and in occupations acquired through university
degrees (e.g., doctors, teachers, and consultants).
2. EMOTIONS: TOWARD AN ONTOLOGICA L REFRAMIN G 17
Van Maanen and Kunda (1989) claimed that
emotions, such as moods, are a matter of contextual
appropriateness put into use. Emotions are
therefore viewed as manageable by oneself and
others, and are largely about being able to act in
an appropriate manner; that is, emotions can be
managed and utilized in an instrumental way, as
is exhibited by knowing how to dress. Furthermore, such competent emotional
labor and management does not depend on deep acting (i.e., the actual feelings
behind the occupational mask) (Hochschild, 1983). One general assumption
in recent studies on emotions in organizations is, according to Sturdy and
Fleming (2001), that surface acting (i.e., expressing feelings that are not felt,
e.g., putting on a smiling mask when one does not feel like smiling) for a period
does not matter because one assumes that surface practicing results in internalization.
Goffmann (1959) described such an internalization process,
where explicit knowledge and emotions become part of the person and thereby
become implicit and deep knowledge and emotions. It seems reasonable that
newcomers or persons who have recently experienced new ideas (e.g., in training)
often, but not always, experience such an internalization process.
When persons "fake it in good faith," as Hochschild (1983) termed it, they
manage the feelings so that they adhere to some standardized "rule" or ideal
(e.g., smile or look sad at the appropriate places), and they have internalized
this formal or informal "rule"—that is, it has become part of the persons and
they understand, identify with, share and follow it. "Faking it in bad faith" is,
on the other hand, when persons put on the same mask, but do so only because
someone else (e.g., their superior) expects them to; they do not understand
the purpose of doing so, or do not share the purpose—rather, they tend to distance
themselves from it (e.g., as a nonbeliever or in a cynical way). "Faking it
in good faith" can be stressful, but some might even see it as fun.

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Care
2004 Edition
New NMS Practice Parameters
Paul D. Chan, MD
Margaret T. Johnson, MD
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Cardiovascular Disorders
Acute Coronary Syndromes
(Acute Myocardial Infarction and
Unstable Angina)
Acute myocardial infarction (AMI) and unstable angina
are part of a spectrum known as the acute coronary
syndromes (ACS), which have in common a ruptured
atheromatous plaque. These syndromes include unstable
angina, non–Q-wave MI, and Q-wave MI. The ECG
presentation of ACS includes ST-segment elevation
infarction, ST-segment depression (including non–Qwave
MI and unstable angina), and nondiagnostic STsegment
and T-wave abnormalities. Patients with STsegment
elevation will usually develop Q-wave MI.
Patients with ischemic chest discomfort who do not have
ST-segment elevation will develop Q-wave MI and
non–Q-wave MI or unstable angina.
I. Clinical evaluation of chest pain and acute coronary
syndromes
A. History. Chest pain is present in 69% of patients
with AMI. The pain may be characterized as a
constricting or squeezing sensation in the chest.
Pain can radiate to the upper abdomen, back,
either arm, either shoulder, neck, or jaw. Atypical
pain presentations in AMI include pleuritic, sharp
or burning chest pain. Dyspnea, nausea, vomiting,
palpitations, or syncope may be the only complaints.
B. Cardiac Risk factors include hypertension,
hyperlipidemia, diabetes, smoking, and a strong
family history (coronary artery disease in early or
mid-adulthood in a first-degree relative).
C. Physical examination may reveal tachycardia or
bradycardia, hyper- or hypotension, or tachypnea.
Inspiratory rales and an S3 gallop are associated
with left-sided failure. Jugulovenous distention
(JVD), hepatojugular reflux, and peripheral edema
suggest right-sided failure. A systolic murmur may
indicate ischemic mitral regurgitation or ventricular
septal defect.
II. Laboratory evaluation of chest pain and acute
coronary syndromes
A. Electrocardiogram (ECG)
1. The hallmark of Q-wave infarction is acute
ST-segment elevation in association with severe
chest pain. Significant ST-segment elevation is
defined as 0.10 mV or more measured 0.02
second after the J point in two contiguous leads,
from the following combinations: (1) leads II, III,
or aVF (inferior infarction), (2) leads V1 through
V6 (anterior or anterolateral infarction), or (3)
leads I and aVL (lateral infarction). Abnormal Q
waves usually develop within 8 to 12 up to 24 to
48 hours after the onset of symptoms. Abnormal
Q waves are at least 30 msec wide and 0.20 mV
deep in at least two leads.
2. Complete left bundle branch block with acute,
severe chest pain should be managed as acute
myocardial infarction pending cardiac marker
analysis. It is usually not possible to definitively
diagnose acute myocardial infarction by the
ECG alone in the setting of left bundle branch
block.
B. Laboratory markers
1. Creatine phosphokinase (CPK) enzyme is
found in the brain, muscle, and heart. The
cardiac-specific dimer, CK-MB, however, is
present almost exclusively in myocardium.
Common Markers for Acute Myocardial Infarction
Marker Initial
Elevation
After
MI
Mean
Time to
Peak
Elevations
Time to
Return
to Baseline
Myoglobin 1-4 h 6-7 h 18-24 h
CTnl 3-12 h 10-24 h 3-10 d
CTnT 3-12 h 12-48 h 5-14 d
CKMB 4-12 h 10-24 h 48-72 h
CKMBiso 2-6 h 12 h 38 h
CTnI, CTnT = troponins of cardiac myofibrils; CPK-MB, MM
= tissue isoforms of creatine kinase.
2. CK-MB subunits. Subunits of CK, CK-MB, -
MM, and -BB, are markers associated with a
release into the blood from damaged cells.
Elevated CK-MB enzyme levels are observed
in the serum 2-6 hours after MI, but may not be
detected until up to 12 hours after the onset of
symptoms.
3. Cardiac-specific troponin T (cTnT) is a
qualitative assay and cardiac troponin I (cTnI)
is a quantitative assay. The cTnT level remains
elevated in serum up to 14 days and cTnI for 3-
7 days after infarction.
4. Myoglobin is the first cardiac enzyme to be
released. It appears earlier but is less specific
for MI than other markers. Myoglobin is most
useful for ruling out myocardial infarction in the
first few hours.
Differential diagnosis of severe or prolonged
chest pain
Myocardial infarction
Unstable angina
Aortic dissection
Gastrointestinal disease (esophagitis, esophageal spasm,
peptic ulcer disease, biliary colic, pancreatitis)
Pericarditis
Chest-wall pain (musculoskeletal or neurologic)
Pulmonary disease (pulmonary embolism, pneumonia,
pleurisy, pneumothorax)
Psychogenic hyperventilation syndrome
III. Initial treatment of acute coronary syndromes
A. Continuous cardiac monitoring and IV access
should be initiated. Morphine, oxygen, nitroglycerin,
and aspirin ("MONA") should be administered
to patients with ischemic-type chest pain
unless contraindicated.
B. Morphine is indicated for continuing pain unresponsive
to nitrates. Morphine reduces ventricular
preload and oxygen requirements by venodilation.
Administer morphine sulfate 2-4 mg IV every 5-10
minutes prn for pain or anxiety.
C. Oxygen should be administered to all patients with
ischemic-type chest discomfort and suspected
ACS for at least 2 to 3 hours.
D. Nitroglycerin
1. Nitroglycerin is an analgesic for ischemic-type
chest discomfort. Nitroglycerin is indicated for
the initial management of pain and ischemia
unless contraindicated by hypotension (SBP
<90 mm Hg) or RV infarction. Continued use of
nitroglycerin beyond 48 hours is only indicated
for recurrent angina or pulmonary congestion.
2. Initially, give up to three doses of 0.4 mg
sublingual NTG every five minutes or nitroglycerine
aerosol, 1 spray sublingually every 5
minutes. An infusion of intravenous NTG may
be started at 10-20 mcg/min, titrating upward
by 5-10 mcg/min every 5-10 minutes (maximum,
3 mcg/kg/min). Titrate to decrease the
mean arterial pressure by 10% in normotensive
patients and by 30% in those with hypertension.
Slow or stop the infusion if the SBP drops
below 100 mm Hg.
E. Aspirin
1. Aspirin should be given as soon as possible to
all patients with suspected ACS unless the
patient is allergic to it. Aspirin therapy reduces
mortality after MI by 25%.
2. A dose of 325 mg of aspirin should be chewed
and swallowed on day 1 and continued PO
daily thereafter at a dose of 80 to 325 mg.
Clopidogrel (Plavix) may be used in patients
who are allergic to aspirin as an initial dose of
75 to 300 mg, followed by a daily dose of 75
mg.
Therapy for acute coronary syndromes
Treatment Recommendations
Antiplatelet
agent Aspirin, 325 mg (chewable)
Nitrates
Sublingual nitroglycerin (Nitrostat), one
tablet every 5 min for total of three
tablets initially,
followed
by IV
form (Nitro-
Bid IV,
Tridil) if
needed
Beta-blocker
IV therapy optional for prompt response,
followed by oral therapy:
Metoprolol (Lopressor), 5 mg IV every 5
min for three doses
Propranolol (Inderal), 1 mg IV; may repeat
every 5 min for total of 5 mg
Esmolol (Brevibloc), initial IV dose of 50
micrograms/kg/min and adjust up to
200-300 micrograms/kg/min
Heparin 60 U/kg IVP, followed by 12 U/kg/hr.
Goal: aPTT, 1.5-2.5 X control
Enoxaparin
(Lovenox)
1 mg/kg IV, followed by 1 mg/kg subcutaneously
bid
Glycoprotein
IIb/IIIa inhibitors
Abciximab (ReoPro), eptifibatide
(Integrilin), or tirofiban (Aggrastat) for
patients with high-risk features in whom
an early invasive approach is planned
Adenosine
diphosphate
receptor-inhibitor
Consider clopidogrel (Plavix) therapy
Cardiac
catheterization
Consideration of early invasive approach
in patients at
intermediate to high risk and those in
whom conservative management
fails

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59
Breast Disorders
Lawrence S. Neinstein

Breast Development and Anatomy
Developmental Anomalies
 
Asymmetrical Breast Development
 
Accessory Breast Tissue (Polymastia)
 
Absence of Breast Tissue (Amastia and Athelia)
 
Atrophy
 
Tuberous Breast Deformity
 
Macromastia
 
Virginal or Juvenile Hypertrophy
Breast Tumors
 
Types of Tumors
 
Benign Breast Disease
 
Proliferative Breast Changes (Nodularity, Fibrocystic Changes)
 
Fibroadenomas and Other Benign Breast Masses
 
Cysts
 
Nipple Discharge
 
Intraductal Papilloma
 
Infections and Inflammations
 
Mastitis
 
Mondor Disease
 
Cancer of the Breast
Diagnosis and Evaluation of Breast Masses in Adolescents
 
History
 
Breast Examination
 
Diagnostic Procedures
 
Management
Summary
Web Sites
 
For Teenagers and Parents
 
For Health Professionals
References and Additional Readings

Although breast cancer is uncommon during the adolescent years, breast concerns and problems among adolescent females are a common occurrence. Breast development often is the first sign of beginning puberty. This chapter reviews breast disorders that can occur in female adolescents and young adults. These include disorders such as asymmetrical breast development, accessory breast tissue, macromastia, benign and malignant breast tumors, and nipple discharges. Galactorrhea (abnormal lactation) is discussed in Chapter 57.
BREAST DEVELOPMENT AND ANATOMY
A mammary ridge or milk line forms from the ectodermal layer in the 20-day-old embryo extending from the forelimb to hind limb. The nipple and areola, which form in the 6th week of fetal life, overlie a bud of breast tissue composed of both the primary mammary ducts and a loose fibrous stroma. Approximately 15 to 25 secondary buds develop, which bifurcate into tubules forming the basis of the duct system. Each duct system opens separately into the nipple.
There is a small amount of breast tissue present in prepubertal children and this usually undergoes no change before puberty. Occasionally, a prepubertal male or female develops enlargement of one or both breasts. This usually consists of a soft, mobile subareolar nodule of uniform consistency. In these individuals, usually the areola and nipple are not developed or pigmented and there are no associated signs of puberty. Spontaneous resolution usually occurs after a few weeks or months. Biopsy should not be performed because this could eliminate pubertal breast development. In some prepubertal individuals, these changes may be the first sign of precocious puberty.
The physiology of breast development during puberty is complex and involves both hormonal levels and the binding of hormones to breast tissue. Multiple hormones are involved including estrogen, progesterone, corticosteroids, and thyroxine. Estrogen, mainly estradiol, has the major influence on ductal development while progesterone influences additional lobular alveolar development. The physiological influences that terminate further breast development are not well understood.
Breasts are usually similar in males and females until puberty. In female adolescents, breast development (thelarche) is usually the first sign of puberty and full breast development is the last sign of female puberty. The details and stages of breast development during puberty are outlined in Chapter 1. However, the average age of thelarche is 11.2 years and ranges from 9.0 to 13.4 years of age.
The milk-producing alveolus, or terminal duct, is the primary unit of the breast and this drains via a branching duct system to the nipple. Each lobule consists of approximately 10 to 100 alveoli and the lobules drain into lactiferous ducts that merge to form a sinus beneath the nipple. The stroma, consisting of fibrous tissue, surrounds and supports the lobules and ducts. Other structures in the breast are lymphatics, fat tissue, and nerves. Most benign breast diseases and almost all breast cancers begin within the terminal duct lobular unit.
Women of reproductive age tend to have breasts that have a nodular texture representing the glandular units or lobules of the breast. During each menstrual cycle, these units undergo proliferative changes under hormonal stimulation. This nodularity can increase, particularly with lobular enlargement and edema that may occur toward the end of menstrual cycles. This process may vary from a feeling of breast fullness to distinct masses suggestive of a pathological process.
After puberty, there are in general three major periods of the breast life cycle.

1.
Breast development: This is the first period and occurs during adolescence up until about age 25 years. During this time, both stromal and lobular units develop. One aberration in lobular development that can occur during this period are fibroadenomas. Another major change can be pregnancy, which can result in an almost doubling of breast weight followed by postpartum involution.

2.
Cyclical activity: Hormonal cyclical changes that occur between age 25 and approximately 40 years. Aberrations during this time can cause cyclical mastalgia and nodularity.

3.
Involution: Involution occurs sometime after age 35 years. At this time, breast stroma is replaced by fat, leading to breasts that are less radiodense and softer. Aberrations at this time can lead to cysts and duct ectasia.
DEVELOPMENTAL ANOMALIES
Asymmetrical Breast Development
In most females, one breast is slightly larger than the other, usually with the left breast larger than the right. However, pubertal breast development does not always occur symmetrically, and for unknown reasons, some adolescents have more significant asymmetry than others during puberty. Much of this corrects by adulthood. Occasionally, when notable asymmetry is present, corrective surgery can be performed with augmentation or reduction of one breast. This can be done in stages with an implant placed in one side that allows for increasing amounts of saline to match growth on the other side. After puberty, this implant is replaced with a permanent implant. One can monitor differences in breast sizes by measuring breast units, which equal vertical distance multiplied by horizontal distance. Some teens may wish to use bra pads for the smaller breast for cosmetic reasons. Breast asymmetry may also be caused by a large mass that may distort breast tissue such as a giant fibroadenoma; these should be examined during the visit. Pseudoasymmetry may result for deformities of the rib cage such as pectus excavatum.
Accessory Breast Tissue (Polymastia)
Accessory breast tissue is the most common breast anomaly, found in 1% to 5% of males and female. Polythelia refers to supernumerary nipples and polymastia to any accessory breast elements. The accessory tissue is usually located along the embryonic milk line anywhere from the midclavicular or axillary area to the middle of the inguinal ligament in the groin. Accessory breast tissue below the umbilicus is extremely rare. This condition has been occasionally associated with cardiovascular and genitourinary anomalies. Although the problem is usually of no significance, the extra nipples may become engorged postpartum and create painful swellings. The extra nipples can be excised for cosmetic reasons. It is important to remember that breast diseases can occur in accessory breast tissue.
Absence of Breast Tissue (Amastia and Athelia)
Amastia is the total absence of one breast. The condition is often associated with an anomaly in the chest wall, including the absence of the pectoralis major or other muscles. Poland syndrome involves a combination of amastia with an ipsilateral rib deformity, webbed fingers, and radial nerve palsy. Certainly, amastia can be extremely disturbing to an adolescent. As described already, surgical correction for amastia can be performed in stages. Atelia is the absence of the nipple on one or both sides. Surgical correction is an option for this condition also.
Atrophy
Atrophy of breast tissue may also occur during puberty. The most common cause of this disorder is a significant loss of fat and supportive glandular tissue related to dieting and eating disorders. Other possible causes include premature ovarian failure, androgen excess (tumors and anabolic steroids), and chronic diseases leading to significant weight loss such as diabetes mellitus, inflammatory bowel disease, and others.
Tuberous Breast Deformity
This deformity involves protuberant and overdeveloped areolae with hypoplasia of other breast areas. It is a benign condition that requires either reassurance or plastic surgery if the defect is severe.
Macromastia
The definition of “normal breast size” is difficult to define accurately and can be a function of society that changes over time. One categorization of breast size (Corriveau and Jacobs, 1990) uses the following:
“ideal breast size”: 250–300 mL
moderate hypertrophy: 400–600 mL
rather significant hypertrophy: 600–800 mL
significant hypertrophy: 800–1,000 mL
gigantomastia: >1,500 mL
There is a strong association between macromastia with obesity and a strong familial incidence. Most cases of macromastia start at the time of puberty, with 80% of cases beginning in adolescence. Macromastia may occur over months to years and may occur before or after menarche.
Female adolescents and their parents usually complain of the psychological effects of macromastia. This is in distinction to female adults who usually complain of breast pain, shoulder grooving, and back pain. No relationship has been found between circulating hormonal levels in these teens and macromastia. However, there may be differences in hormone-receptor affinity.

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58
Hirsutism and Virilization
Catherine M. Gordon and Lawrence S. Neinstein

Hair Physiology
Androgen Physiology
Differential Diagnosis
Diagnosis
 
Indications for Evaluation
 
History
 
Physical Examination
 
Laboratory Evaluation
Therapy
Web Sites
 
For Teenagers and Parents
 
For Health Professionals
References and Additional Readings

Hirsutism is defined as increased growth of terminal (long, coarse, and pigmented) hair in a young woman, in an amount more than is cosmetically acceptable in a certain culture. The condition commonly refers to an increase in length and coarseness of the hair, in a male pattern, including predominantly midline hair of the upper lip, chin, cheeks, inner thighs, lower back, and periareolar, sternal, abdominal, and intergluteal regions. Virilism implies the development of male secondary sex characteristics in a woman. This may include the following:

1.
Defeminizing symptoms: Vaginal wall atrophy, decreased vaginal secretions, decreased breast tissue, oligomenorrhea, and amenorrhea

2.
Masculinizing symptoms: Hirsutism, deepened voice, increased libido, increased muscle mass, clitoromegaly (>5-mm diameter), temporal balding, and acne
Hypertrichosis implies the predominance of excessive vellus hair on the body, particularly the forehead, forearms, and lower legs.
Androgen excess, or hyperandrogenism, results in appearance changes in a young woman and can be associated with abnormal menstrual patterns, infertility, and metabolic disturbances that include decreased high-density lipoprotein cholesterol level, insulin resistance, decreased sex hormone-binding globulin (SHBG), and alterations in the balance between thromboxane and a2-prostacyclin (Haseltine et al., 1994). A common cause of hyperandrogenism, polycystic ovary syndrome (PCOS), can increase a patient's risks for developing obesity, type 2 diabetes mellitus, and cardiovascular disease (Gordon, 1999). These young women can also have increased levels of plasminogen-activator inhibitor-1, which inhibits fibrinolysis and is a risk factor for myocardial infarction (Ehrmann et al., 1997).
Androgen disorders must be evaluated, particularly in female adolescents, because appropriate interventions are now available. The evaluation does not require complicated, expensive procedures; and if untreated, the hyperandrogenism will persist and can lead to excess morbidity and psychosocial dysfunction. It is also important to delineate the etiology of the hyperandrogenism so an appropriate management plan can be developed around a specific diagnosis (e.g., PCOS and late-onset congenital adrenal hyperplasia).
HAIR PHYSIOLOGY
Hair grows from hair follicles that develop at 8 weeks of gestation. All hair follicles are developed in utero, and no new follicles develop during life. The concentration of hair follicles per unit area of skin is similar in males and females but differs between races and ethnic groups. Whites have a greater concentration than Asians, and Mediterranean people have a greater concentration than individuals of Nordic descent. Hair grows in cycles according to the following phases:

1.
Anagen phase: Growing phase

2.
Catagen phase: Rapid involution phase

3.
Telogen phase: Resting phase
Hair length is determined by the duration of the growing phase. Factors influencing hair growth include the following:

1.
Androgens: Androgens initiate hair growth and increase hair diameter and pigmentation. These changes occur secondary to dihydrotestosterone (DHT) conversion of vellus hair to terminal hair. Once hair growth is established, the pattern may continue despite androgen withdrawal, albeit at a slower rate. Once the androgen level is reduced, there may be a lag time of 6–9 months before a significant change is noticed, as old terminal hairs fall out and are replaced by new vellus hairs.

2.
Estrogens: Estrogens retard initiation and the rate of hair growth and may prolong the anagen phase.
The effects of sex hormones and other factors on hair development and distribution can be more easily understood by considering the pilosebaceous unit (Fig. 58.1). The clinical manifestations of androgen excess vary depending on end-organ sensitivity to androgens, as is shown. Hirsutism can result either from overproduction or increased sensitivity of hair follicles to androgens. Terminal hair growth is stimulated by the increased conversion of testosterone to DHT from excess 5a-reductase within this unit or the presence of more numerous hair follicles.

FIG. 58.1. Effect of ovarian androgens on the pilosebaceous unit. Within the ovarian theca cell, insulin and LH may stimulate cytochrome P450c17a activity, resulting in increased 17a-hydroxylase and 17,20-lyase activity, as denoted by asterisks above. These two enzymes comprise the P450c17a complex. Ovarian testosterone, along with DHT from 5a-reductase within the pilosebaceous unit, stimulates the androgen receptors at the hair follicle and sebaceous glands. Hirsutism and acne can result. (From Gordon CM. Menstrual disorders in adolescents: excess androgens and the polycystic ovary syndrome. Pediatr Clin North Am 1999;46:519–543, with permission.)

ANDROGEN PHYSIOLOGY
Androgens are synthesized during the metabolic pathways of progesterone, cortisol, and estrogen (Fig. 58.2).

FIG. 58.2. Ovarian steroid biosynthetic pathways. The following enzymes are required where indicated: (a) 20-hydroxylase, 22-hydroxylase, and 20,22-desmolase; (b) 3b-hydroxysteroid dehydrogenase and D5®D4-isomerase; (c) 17a-hydroxylase; (d) 17,20-lyase; (e) 17b-hydroxysteroid dehydrogenase; and (f) aromatizing enzyme system. (From Goebelsmann U. Steroid hormones. In: Mishell DR Jr, Davajan V, eds. Infertility, contraception, and reproductive endocrinology. Oradell, NJ: Medical Economics, 1986, with permission.)

1.
Circulating androgenic steroids in females

a.
17-Ketosteroids (17-KSs)

Dehydroepiandrosterone sulfate (DHEAS)

Dehydroepiandrosterone (DHEA)

Androstenedione

b.
17b-Hydroxysteroids

Testosterone

DHT

Androstenediol

3b-Androstenediol

2.
Metabolism: Androgens originate in the adrenal gland and ovaries, either via direct secretion or peripheral conversion of precursors. DHEAS, DHEA, and androstenedione, which are mainly produced in the adrenal gland, exert their androgenic activity after peripheral conversion to testosterone or its metabolites.

a.
Adrenal secretion: Androgens are by-products of cortisol synthesis.

17-KSs: Most of the 17-KSs are generated from adrenal sources. This includes a daily secretion of 7 mg of DHEAS (90% of total daily secretion), 5.5 mg of DHEA, and 1.8 mg of androstenedione (50% of total daily secretion). All of these compounds have low androgenic activity because they are precursors of testosterone.

Testosterone: 25% is derived from adrenal secretion, or a total of 0.06 mg/day is secreted from the adrenal gland. Testosterone is a potent androgen, although the most potent androgen is DHT, formed after conversion by 5a-reductase.

b.
Ovarian secretions: Androgens from the ovary are metabolized as intermediates in the production of estrogen and progesterone. Androgenic hormones secreted by the ovary include the following:

Testosterone: About 25% of total daily secretion (0.06 mg/day)

Androstenedione: About 50% of total daily secretion (1.7 mg/day)

c.
Peripheral conversion: About 50% of testosterone is derived from peripheral conversion of androstenedione in liver, fat, and skin cells.

d.
Testosterone is 95.5% bound to SHBG in females; only the free portion is active. During pregnancy, about 99% is bound. In healthy males, 92.8% of testosterone is bound.

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57
Galactorrhea
Norman P. Spack and Lawrence S. Neinstein

Etiology
Differential Diagnosis
Diagnosis
Therapy
 
Specific Therapeutic Options
Web Sites
 
For Teenagers and Parents
 
For Health Professionals
References and Additional Readings

Galactorrhea, the inappropriate secretion of a clear or milky fluid from one or both breasts, is nonphysiological because it is not related to pregnancy or breast feeding. Yellow, greenish, or blood-tinged fluid is suggestive of local breast disease. Galactorrhea is often accompanied by amenorrhea and warrants evaluation in any nulliparous female or in a parous woman if one or more years have elapsed since the last pregnancy or weaning.
ETIOLOGY
Prolactin secretion is necessary for normal lactation, with the breast being the primary target for prolactin secreted by lactotroph cells of the anterior pituitary under the neuroendocrine control of hypothalamic prolactin-releasing factors and prolactin-inhibiting factors. Regulation is predominantly mediated by dopamine, which traverses the hypothalamic-pituitary portal vasculature and binds to the lactotrophs, where it inhibits prolactin secretion. Transection or compression of the pituitary stalk, which typically decreases secretion of nearly all pituitary hormones, increases prolactin secretion via interference with dopamine's ability to reach the lactotrophs. Psychotropic drugs, such as phenothiazines and butyrophenones (including haloperidol), interfere with dopamine's inhibition of prolactin by blocking dopamine receptors. Prolactin is also stimulated by a number of other releasing factors, including serotonin, vasoactive intestinal peptide, and hypothalamic thyrotropin-releasing hormone (TRH), which explains the occurrence of galactorrhea in cases of primary hypothyroidism. A schema of prolactin control is shown in Fig. 57.1.

FIG. 57.1. Schema of prolactin control. Prolactin-inhibiting factors (PIFs), Prolactin-releasing factors (PRFs).

Galactorrhea may be the result of medication use, hypothalamic-pituitary lesions, thyroid dysfunction, chronic renal disease, or unknown factors that alter normal physiological feedback or increase the number of lactotrophs, as in anterior pituitary adenomas. Normal prolactin and lactation physiology includes the following:

1.
Pregnancy: Breast glandular tissue increases in the presence of elevated levels of estrogen, progesterone, and prolactin.

2.
Postpartum: Falling levels of estrogen and progesterone promote prolactin release, as does suckling, via stimulation of afferent neural pathways to the hypothalamus, resulting in lactation.

3.
Other hormonal effects of prolactin

a.
High prolactin levels may lower gonadotropin-releasing hormone (GnRH), thereby reducing luteinizing hormone and follicle-stimulating hormone, resulting in oligomenorrhea or amenorrhea and ultimately lowering ovarian estrogen production.

b.
Stimulation of prolactin

TRH: Direct pituitary stimulation

Serotonin reuptake inhibitors

Phenothiazines, reserpine, methyldopa, pyrimidines (risperidone), tricyclic antidepressants, metoclopramide, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors (all via presumed interference with dopamine secretion or action)

c.
Inhibition of prolactin

Levodopa

Ergot alkaloids (e.g., bromocriptine and cabergoline, which are dopamine receptor agonists)

Serotonin antagonists
DIFFERENTIAL DIAGNOSIS
The differential diagnosis for hyperprolactinemia is listed in Table 57.1. The differential diagnosis for galactorrhea may be complex due to numerous factors that control prolactin secretion in preparation for pregnancy and lactation. Galactorrhea has been reported in males attempting to rid themselves of “functional” gynecomastia by means of excessive breast manipulation.

TABLE 57.1. Differential diagnosis for hyperprolactinemia

Exogenous estrogen (e.g., high-estrogen-content birth control pills) has been linked to mild hyperprolactinemia and galactorrhea. Oral contraceptives, however, are incapable of produ- cing pituitary adenomas, and the lower dose pills currently used have a lower prevalence of galactorrhea. Galactorrhea related to estrogens, antipsychotics, and other medication does not usually persist longer than 3 to 6 months after discontinuation of the offending drug.
DIAGNOSIS
Multiple factors must be considered in the evaluation and treatment of hyperprolactinemia-induced galactorrhea (Fig. 57.2). Because prolactin is secreted in pulsatile fashion, augmented by breast stimulation or examination, exercise, stress, and eating, serum elevations should be confirmed by several repeated samples drawn in a fasting state avoiding the previously mentioned precipitants. Persistent hyperprolactinemia unassociated with pregnancy, renal failure, hypothyroidism, or the use of medications known to induce hyperprolactinemia warrants a cranial magnetic resonance imaging (MRI) study with gadolinium enhancement to evaluate the pituitary.

FIG. 57.2. Flowchart of evaluation for galactorrhea.

Symptoms in women tend to be proportional to circulating prolactin concentrations. A given level of hyperprolactinemia is less likely to produce galactorrhea in a male, because estrogen levels must be sufficiently high to prime the mammary glands and ducts. Men may experience infertility or impotence and typically present later in the course of a macroprolactinoma when the mass effect from a growing tumor induces headaches or visual field changes. Delay in pubertal development may occur in either sex via the GnRH suppression induced by elevated prolactin.
The level of serum prolactin is somewhat useful for predicting diagnosis:

1.
Reference-range prolactin levels in a patient with galactorrhea and normal menses virtually rule out a pituitary tumor.

2.
Prolactin levels <100 ng/mL are often unassociated with a discrete tumor, and any tumor found is unlikely to be composed of lactotrophs. The hyperprolactinemia is probably the result of compressive interference with dopamine pathways.

3.
Levels of 100–250 ng/mL are more often associated with a microadenoma (<10 mm diameter).

4.
Levels >250 ng/mL are usually secondary to macroadenomas (>10 mm diameter).
Kane et al. (1994) evaluated the signs, symptoms, and outcomes of 56 children and adolescents with pituitary adenomas, as did Colao et al. (1998) in 26 patients diagnosed at age 7 to 17 years.

1.
Types of adenoma: Macroadenomas were more common than microadenomas in both studies. The tumor histochemistry of the 56 patients in the series by Kane et al. (1994) was as follows:

a.
Prolactin alone, 41

b.
Prolactin and growth hormone, 8

c.
Multiple hormones, 6

d.
Glycoproteins, 1

2.
Prevalence by sex

a.
No males had microadenomas in the study by Kane et al. (1994); in the review by Colao et al. (1998), one male had a microadenoma presenting with arrested skeletal growth.

b.
Females outnumbered males by a ratio of 3.3:1. All of the females in the study by Colao et al. (1998) presented with primary or secondary amenorrhea.

3.
Symptoms: Headache, menstrual dysfunction, galactorrhea, and symptoms related to hypopituitarism were most frequent. Macroadenomas were found in all but one of the patients who presented with hypopituitarism.
THERAPY

1.
Oral contraceptives: 40% of patients using oral contraceptives have mildly elevated basal prolactin levels (20–40 ng/mL) and most do not have galactorrhea. If galactorrhea occurs, the oral contraceptive should be stopped for 1 month and prolactin levels retested.

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56
Ectopic Pregnancy
Anita L. Nelson and Lawrence S. Neinstein

Incidence
Etiology
Risk Factors for Ectopic Pregnancy
Differential Diagnosis
Clinical Presentations
 
Acute Presentation: Classic, Ruptured Ectopic Pregnancy
 
Subacute Presentations: Probable Ectopic Pregnancy and Possible Ectopic Pregnancy
 
Outpatient Workup
Impacts on Future Fertility
Web Sites
 
For Teenagers and Parents
 
For Health Professionals
References and Additional Readings

INCIDENCE
Ectopic pregnancies must be considered in the differential diagnosis of the pregnant adolescent with pelvic pain, particularly early in gestation if such pain is associated with abnormal uterine spotting or bleeding. A useful approach to reproductive-age women with pelvic pain or irregular bleeding is to assume that they are pregnant until proven otherwise and that all pregnancies are ectopic until proven otherwise. The number of ectopic pregnancies increased from 17,800 (4.8/1,000 livebirths) in 1970 to 108,800 (19.7/1,000) in 1992 (Centers for Disease Control and Prevention [CDC], 1995). This rise in ectopic pregnancies has been attributed to early detection (many early ectopic pregnancies that resolved spontaneously would previously have gone undetected); to an increase in salpingitis, tubal damage, and other risk factors; and to the high recurrence rate for ectopic pregnancies treated conservatively. In 1992, ectopic pregnancies accounted for 2% of reported pregnancies and 13% of all pregnancy-related deaths. Ectopic pregnancies are now the second leading cause of maternal mortality in the United States and the leading cause of maternal death during the first half of pregnancy (Atrash et al., 1987). Although the overall death-to-case rates have declined by nearly 90% (from 35.5 per 10,000 ectopic pregnancies in 1970 to 3.8 per 10,000 in 1989), the risk of death from ectopic pregnancy is 50 times greater than the risk of death from legal abortion and 10 times greater than the mortality risk associated with childbirth. Washington and Katz (1993) estimated that the total cost of ectopic pregnancies in the United States in 1990 was $1.1 billion, with hospitalization and other medical treatments contributing to 77% of the total costs. The systematic use of sensitive quantitative tests for pregnancy hormones (b-human chorionic gonadotropin [b-hCG]) and transvaginal ultrasound to identify early intrauterine pregnancies has revolutionized the diagnosis of ectopic pregnancy and permitted medical management to replace surgical management in uncomplicated cases. This has reduced complication rates and overall costs for treatment.
ETIOLOGY
The precise cause of ectopic implantation is not clear, but several hypotheses have been suggested (Chavkin, 1982; Corson and Batzer, 1986; Marchbanks et al., 1988).

1.
Delayed ovulation and fertilization: Implantation usually occurs 7 days after fertilization. If either ovulation or fertilization is delayed, the blastocyst may not have time to implant in the endometrium but may be swept by menstrual flow black into the tubal lumen. Transmigration has been used to explain ectopic pregnancy on this basis as well; 30% to 50% of ectopic pregnancies occur when the corpus luteum is on the side opposite the tubal pregnancy. However, this evidence is not conclusive, because women with single ovaries on the side opposite their single fallopian tubes are not at increased risk for ectopic pregnancy. Another special risk group is women undergoing in vitro fertilization (IVF), when the hydraulic force used to place the embryos into the endometrium can transport one or more of them through the tubal ostium into the fallopian tube.

2.
Slowed tubal motility or damaged fallopian tubes: If the progression of the fertilized ovum is delayed through the tube because of distorted tubal anatomy or slowed tubal flow, the zona pellucida covering the conceptus may have time to shed and permit tubal implantation in the fallopian tube. Previous pelvic inflammatory disease (PID) is the most common cause of abnormal tubal anatomy (see Chapter 63); tubal motility derangement is most frequently caused by hormonal imbalance.

3.
Endometrial abnormalities: The lack of appropriate intrauterine implantation sites might block pregnancy establishment inside the uterine cavity, and combined with contractions and menstrual flow, may facilitate ectopic implantation. Polyps, intrauterine septa, and submucous myomas can contribute to this problem. Progestin-containing contraceptives induce profound atrophic changes on the endometrium, which may block intrauterine implantation. IUDs create inflammatory changes in the uterine lining but do not increase ectopic pregnancy rates.

4.
Defects in ovum: The clinical significance of ovum issues is not clear. Some DNA flow cytometry studies have revealed that one third of ectopic human concepti have aneuploidy (Karikoski et al., 1993). This observation was supported by microdissection and histological sections, which found that more than one half of women had fetuses with structural abnormalities (Stratford, 1970). The impact this has on incorrect implantation is unknown. On the other hand, culture techniques have indicated that ectopic pregnancies have no higher frequency of chromosomal abnormalities than similar-age intrauterine pregnancies (Elias et al., 1981), and more recent karyotyping studies have failed to find any increased incidence of chromosomal abnormalities in ectopic pregnancies (Coste et al., 2000).
RISK FACTORS FOR ECTOPIC PREGNANCY

1.
Tubal abnormalities: The most common risk factor for tubal abnormalities is previous tubal infection (Brenner et al., 1980). Evidence of previous tubal inflammation has been found in 40%–50% of tubal pregnancies (Chavkin, 1982). Most women with gonococcal salpingitis are likely to be aware of their risks because gonococcal pelvic infections provide significant pain and discomfort. However, women with a history of chlamydial infections may not be able to relate this risk factor, because chlamydial salpingitis has a more subtle clinical presentation; the heat shock proteins elaborated by Chlamydia trachomatis can produce significant tubal damage while causing only minimal symptomatology. Tubal problems can also be caused by diethylstilbestrol exposure, previous ectopic pregnancy, prior tubal surgery for sterilization or infertility, prior ectopic pregnancy, or tubal adhesions from previous appendicitis or abdominopelvic surgery. Salpingitis isthmica nodosa is an intrinsic tubal defect that also increases ectopic risk and is found ten times more often in patients with tubes with ectopic implantations than in control subjects.

2.
Pregnancy after tubal ligation or with IUD or progestin-only contraceptives: The absolute risk of ectopic pregnancy is significantly reduced by each of these methods of birth control compared with women who use no method of contraception. However, if a pregnancy occurs, the risk that the fetus will implant ectopically is increased. For example, 15%–50% of pregnancies after tubal ligation are ectopic (this percentage increases with time since surgery), and 5%–8% of pregnancies in copper IUD users are ectopic. A history of previous IUD use does not increase a woman's risk of ectopic pregnancy after the IUD has been removed for at least a month.

3.
Unexplained infertility is also a risk factor, particularly in women with normal menstrual cycles.

4.
Assisted reproductive technology dramatically increases the risk of ectopic pregnancy. Overall, 5% of IVF pregnancies are ectopic, and at least 1% are heterotopic (i.e., an ectopic pregnancy in conjunction with an intrauterine pregnancy). About 4% of pregnancies resulting from gamete intrafallopian transfer are ectopic.

5.
Other risk factors include vaginal douching and smoking (which more than doubles the risk for ectopic pregnancy).
DIFFERENTIAL DIAGNOSIS
The differential diagnosis includes the following (Table 56.1):

TABLE 56.1. Differential diagnosis of ectopic pregnancy

1.
PID

2.
Normal intrauterine pregnancy

3.
Threatened or spontaneous abortion

4.
Appendicitis

5.
Hemorrhagic corpus luteum cyst

6.
Torsion of the adnexa (fallopian tube and/or ovary)

7.
Ruptured ovarian cyst

8.
Acute gastroenteritis

9.
Ruptured endometrioma, endometriosis

10.
Diverticulitis